Noninvasive evaluation of cardiac risk before elective vascular surgery

The prognostic utility for predicting cardiac events was determined for dipyridamole-thallium scintigraphy, exercise stress testing (when possible; n = 69) and multiple clinical variables in 100 consecutive patients admitted for elective surgical repair of peripheral vascular disease. After initial noninvasive evaluation, 11 patients were referred for coronary angiography and the remaining 89 patients had surgery without further cardiac studies. Fifteen patients (17%) had a postoperative myocardial infarction, one of which was fatal. Of these 15 patients, 14 had thallium redistribution and 3 had positive ST segment depression during stress testing. Among the many variables tested, the presence of redistribution on serial dipyridamole-thallium images was the most significant predictor of serious cardiac events. All 11 patients who had coronary angiography had both redistribution and multivessel coronary artery disease. Four of these 11 patients died during follow-up and 6 had coronary artery bypass surgery. It is concluded that dipyridamole-thallium imaging has significant prognostic utility in predicting postoperative myocardial infarction and death in patients with severe peripheral vascular disease, and is superior to exercise testing or clinical variables in determining cardiac risk. The odds for a serious cardiac event were 23 times greater in a patient with thallium redistribution than in a patient without redistribution, strongly suggesting that myocardial imaging may be used as a primary screening test before elective vascular surgery.     

Role of multimodality cardiac imaging in preoperative cardiovascular evaluation before noncardiac surgery

The preoperative cardiac assessment of patients undergoing noncardiac surgery is common in the daily practice of medical consultants, anesthesiologists, and surgeons. The number of patients undergoing noncardiac surgery worldwide is increasing. Currently, there are several noninvasive diagnostic tests available for preoperative evaluation. Both nuclear cardiology with myocardial perfusion single photon emission computed tomography (SPECT) and stress echocardiography are well-established techniques for preoperative cardiac evaluation. Recently, some studies demonstrated that both coronary angiography by gated multidetector computed tomography and stress cardiac magnetic resonance might potentially play a role in preoperative evaluation as well, but more studies are needed to assess the role of these new modalities in preoperative risk stratification. A common question that arises in preoperative evaluation is if further preoperative testing is needed, which preoperative test should be used. The preferred stress test is the exercise electrocardiogram (ECG). Stress imaging with exercise or pharmacologic stress agents is to be considered in patients with abnormal rest ECG or patients who are unable to exercise. After reviewing this article, the reader should develop an understanding of the following: (1) the magnitude of the cardiac preoperative morbidity and mortality, (2) how to select a patient for further preoperative testing, (3) currently available noninvasive cardiac testing for the detection of coronary artery disease and assessment of left ventricular function, and (4) an approach to select the most appropriate noninvasive cardiac test, if needed.     

Cerebral vascular accident after cardiac surgery: its impact on nursing care.

The number of patients undergoing coronary artery bypass grafting (CABG) per year is increasing. Despite advances in surgical techniques, cerebral vascular accident (CVA) post cardiac surgery is increasing. CVA is a severe neurological complication of cardiac surgery which increased length of stay, morbidity and mortality, and rehabilitation. It is important to identify patients at increased risk and utilize appropriate screening techniques to decrease the incidence of CVA. Nursing assessment, interventions, and postoperative neurological assessment is crucial in identifying patients at increased risk for CVA.     

Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery

STUDY OBJECTIVE: To determine whether clinical markers and preoperative dipyridamole-thallium imaging are both useful in predicting ischemic events after vascular surgery. DESIGN: Retrospective, observational study. SETTING: University medical center. PATIENTS: Two hundred fifty-four consecutive patients referred to a nuclear cardiology laboratory before surgery. Forty-four patients had surgery cancelled or postponed after clinical evaluation and dipyridamole-thallium imaging. Surgery was not confirmed for ten. Two hundred patients receiving prompt vascular surgery were the study group. MEASUREMENTS AND MAIN RESULTS: Thirty patients (15%) had early postoperative cardiac ischemic events, with cardiac death in 6 (3%) and nonfatal myocardial infarction in 9 (4.5%). Logistic regression identified five clinical predictors (Q waves, history of ventricular ectopic activity, diabetes, advanced age, angina) and two dipyridamole-thallium predictors of postoperative events. Of patients with none of the clinical variables (n = 64), only 2 (3.1%; 95% CI, 0% to 8%) had ischemic events with no cardiac deaths. Ten of twenty (50%; 95% CI, 29% to 71%) patients with three or more clinical markers had events. Eighteen of one hundred sixteen (15.5%; 95% CI, 7% to 21%) patients with either 1 or 2 clinical predictors had events. Within this group, 2 of 62 (3.2%; 95% CI, 0% to 8%) patients without thallium redistribution had events compared with 16 events in 54 patients (29.6%; 95% CI, 16% to 44%) with thallium redistribution. The multivariate model using both clinical and thallium variables showed significantly higher specificity at equivalent sensitivity levels than models using either clinical or thallium variables alone. CONCLUSIONS: Preoperative dipyridamole-thallium imaging appears most useful to stratify vascular patients determined to be at intermediate risk by clinical evaluation. For patients with one or two clinical predictors, thallium redistribution correlates with substantial change in probability of events. For nearly half the patients, however, thallium imaging may have been unnecessary because of very high or low cardiac risk predicted by clinical information alone.     

Use of positron emission tomography for prediction of perioperative and late cardiac events before vascular surgery

The efficacy of myocardial perfusion imaging for cardiac-risk stratification of patients undergoing vascular surgery has been disputed recently. In comparison with conventional techniques, positron emission tomography (PET) has the benefit of permitting a true resting scan, allows accurate measurement of the extent of ischemia, and is highly specific for the diagnosis of coronary disease. We therefore investigated the use of PET for risk stratification at the time of vascular surgery and subsequent follow-up in 78 patients (aged 67 ± 11 years, 52 men), selected for testing before the performance of extensive surgery or because of one or more clinical risk factors. Perfusion images were obtained by using a standard rubidium 82 protocol before and after dipyridamole-handgrip stress. With use of a quantitative color scale in a 24-segment model of the left ventricle, scans were reported as showing normal perfusion, resting defects, or stress-induced defects (deterioration>15% with stress). After exclusion of 6 patients referred for myocardial revascularization, 72 patients were followed up in the perioperative period and for 18 ± 12 months for late cardiac death, myocardial infarction, or unstable angina. Perioperative events occurred in 14 patients (5 with myocardial infarction and 9 with unstable angina), 10 of whom had ischemia at PET (sensitivity, 71%; predictive value of a positive test, 45%). Isolated resting perfusion defects were not associated with events. The presence of extensive ischemia (more than five segments) had a positive predictive value of 64%, and its absence gave a negative predictive value of 89%. Ischemia was present in 12 (p = 0.003) of 59 patients without events (specificity, 79%; predictive value of a negative test, 92%). Seven patients had late events (2 with myocardial infarction and 5 with unstable angina). Of 21 patients with either an early or a late event, 14 had a stress-induced perfusion defect (sensitivity, 67%; predictive value, 64%), whereas of 52 with no event, 8 had stress-induced defects (specificity, 84%). PET appears to be an effective technique for stratification of cardiac risk in patients undergoing vascular surgery. This technique may be a useful alternative to conventional imaging in patients with previous infarction or known resting wall-motion abnormalities, because it shows differing prognostic implications of patients with resting and stress-induced perfusion defects.     

Negative impact of sedation on esophagogastric junction evaluation during esophagogastroduodenoscopy

AIM:To compare the esophagogastric junction(EGJ)areas observed in sedated and non-sedated patients during esophagogastroduodenoscopy(EGD).METHODS:Data were collected prospectively from consecutive patients who underwent EGD for various reasons.The patients were divided into three groups according to the sedation used:propofol,midazolam,and control(no sedation).The EGJ was observed during both insertion and withdrawal of the endoscope.The extent of the EGJ territory observed was classified as excellent,good,fair,or poor.In addition,the time the EGJ was observed was estimated.RESULTS:The study included 103 patients(50 males;mean age 58.44±10.3 years).An excellent observation was achieved less often in the propofol and midazolam groups than in the controls(27.3%,28.6%and91.4%,respectively,P<0.001).There was a significant difference in the time at which EGJ was observed among the groups(propofol 20.7±11.7 s vs midazolam 16.3±7.3 s vs control 11.6±5.8 s,P<0.001).Multivariate analysis showed that sedation use was the only independent risk factor for impaired EGJ evaluation(propofol,OR=24.4,P<0.001;midazolam,OR=25.3,P<0.001).Hiccoughing was more frequent in the midazolam group(propofol 9%vs midazolam25.7%vs control 0%,P=0.002),while hypoxia(SaO2<90%)tended to occur more often in the propofol group(propofol 6.1%vs midazolam 0%vs control 0%,P=0.101).CONCLUSION:Sedation during EGD has a negative effect on evaluation of the EGJ.     

Preoperative strategies to assess cardiac risk before noncardiac surgery

The strategies recommended in the preoperative cardiac risk assessment prior to major vascular and nonvascular surgery are reviewed. The role of clinical evaluation, noninvasive stress testing (exercise test, stress myocardial perfusion imaging, stress echocardiography), and Holter monitoring during the preoperative evaluation are outlined and the value of intervention based on the use of each test is discussed. Recommended strategies to evaluate patients based on their clinical risk markers in addition to the results of the noninvasive risk assessment are presented.     

Negative prognostic impact of sarcopenia before and after neoadjuvant chemotherapy for pancreatic cancer

ObjectivesTo elucidate the prognostic impact of sarcopenia before and after neoadjuvant chemotherapy (NAC) for pancreatic cancer (PC).MethodsWe retrospectively studied 75 consecutive PC patients who underwent neoadjuvant gemcitabine plus S-1 combination therapy followed by pancreatectomy between 2008 and 2016. According to the skeletal muscle volume index (SMI), the patients were divided into the muscle attenuation group (MAG) and normal group (NG) before or after NAC. Prognostic factors for overall survival (OS) were analyzed by Cox proportional hazards models.ResultsThe MAG showed significantly poorer OS than the NG before and after NAC. Pre-NAC, median OS was 20.0 months in the MAG versus 49.0 months in the NG (p = 0.006). Post-NAC, median OS was 21.3 months in the MAG versus 48.8 months in the NG (p = 0.014). Multivariate analysis, excluding muscle attenuation after NAC because of confounding factors and lower hazard ratio (2.08, 95% confidence interval: 1.14–3.78, p = 0.016) than that before NAC (2.14, 1.23–3.70, p = 0.007) by univariate analysis, revealed the following independent prognostic factors: muscle attenuation pre-NAC (2.25, 1.26–4.05, p = 0.007); borderline resectability (1.96, 1.04–3.69, p = 0.038); operative blood loss (2.60, 1.38–4.88, p = 0.003); and distant metastasis (3.31, 1.40–7.82, p = 0.006).ConclusionsSarcopenia before and after NAC for PC is suggested to be a poor prognostic factor, with a stronger impact before than after NAC.